Look inside for an overview of your benefits and what’s new for the 2017-18 plan year.
Weber State University
PROUDLY SERVING UTAH PUBLIC EMPLOYEES
Enrollment Guide2017-2018
Welcome to PEHPWe want to make accessing and understanding your healthcare benefits simple. This Benefits Summary contains important information on how best to use PEHP’s comprehensive benefits. Please contact the following PEHP departments or affiliates if you have questions.
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IntroductionContact Information
ON THE WEB»Website . . . . . . . . . . . . . . . . . . . . . . . . . .www .pehp .org
Create an online personal account at www .pehp .org to review your claims history, receive important information through our Message Center, see a comprehensive list of your coverages, use the Cost & Quality Tools to find providers in your network, access Healthy Utah rebate information, check your FLEX$ account balance, and more .
CUSTOMER SERVICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .801-366-7555 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-765-7347
Weekdays from 8 a .m . to 5:30 p .m . Have your PEHP ID or Social Security number on hand for faster service . Foreign language assistance available .
PREAUTHORIZATION»Inpatient hospital preauth . . . . . . . . .801-366-7755 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-753-7754
MENTAL HEALTH/SUBSTANCE ABUSE PREAUTHORIZATION »PEHP Customer Service . . . . . . . . . . . 801-366-7555 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-765-7347
PRESCRIPTION DRUG BENEFITS»PEHP Customer Service . . . . . . . . . . . 801-366-7555 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-765-7347
»Express Scripts . . . . . . . . . . . . . . . . . . . .800-903-4725 . . . . . . . . . . . . . . . . . . . . . . . . . www .express-scripts .com
SPECIALTY PHARMACY »Accredo . . . . . . . . . . . . . . . . . . . . . . . . . . .800-501-7260
PEHP FLEX$»PEHP FLEX$ Department . . . . . . . . . .801-366-7503 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-753-7703
HEALTH SAVINGS ACCOUNTS (HSA)»PEHP FLEX$ Department . . . . . . . . . .801-366-7503 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-753-7703
»HealthEquity . . . . . . . . . . . . . . . . . . . . . .866-960-8058 . . . . . . . . . . . . . . www .healthequity .com/stateofutah
PRENATAL AND POSTPARTUM PRO-GRAM»PEHP WeeCare . . . . . . . . . . . . . . . . . . . .801-366-7400 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 855-366-7400 . . . . . . . . . . . . . . . . . . . . . . . . . . www .pehp .org/weecare
WELLNESS AND DISEASE MANAGEMENT»PEHP Healthy Utah . . . . . . . . . . . . . . . .801-366-7300 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 855-366-7300 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .www .healthyutah .org
»PEHP Waist Aweigh . . . . . . . . . . . . . . 801-366-7300 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 855-366-7300
»PEHP Integrated Care . . . . . . . . . . . . .801-366-7555 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or 800-765-7347
VALUE-ADDED BENEFITS PROGRAM»PEHPplus . . . . . . . . . . . . . . . . . . www .pehp .org/plus
»Blomquist Hale . . . . . . . . . . . . . . . . . . . .800-926-9619 . . . . . . . . . . . . . . . . . . . . . . . . . www .blomquisthale .com
CLAIMS MAILING ADDRESSPEHP560 East 200 SouthSalt Lake City, UT 84102-2004
Open EnrollmentApril 10-May 15 » This is the time to enroll in or make changes to your benefits. If you want to keep your current selections, you don’t have to do anything. However, take this time to review your choices and learn more about the PEHP benefits available to you.
IntroductionIntroduction
Inpatient RehabilitationInpatient rehabilitation will be limited to 45 days per plan year.
On-Demand DoctorsSee a doctor via mobile or web with discounted PEHP pricing through Amwell On-Demand Doctors. It’s available 24 hours a day, every day, and you don’t need an appointment.
PEHP Value ClinicsMake one of these full-service clinics your family doctor and save! They provide all the services of a family doctor, but at a lower cost.
Autism BenefitAutism benefit details are included in this book.
STAR Plan Individual CapAs part of the Affordable Care Act (ACA), when services are provided by an in-network provider, individual members cannot spend more than $7,150 on family STAR plans.
FLEX$ CoverageReminder that you must enroll each year in order to maintain a FLEX$ account.
PharmacyPEHP’s Preferred Drug List is modified periodically with changes based on recommendations from PEHP’s Pharmacy and Therapeutics Committee.
Message CenterVisit the Message Center at www.pehp.org. This tool allows PEHP to send announcements, messages, and forms that directly relate to our members’ needs and concerns.
CHANGES AND REMINDERS
Information in this open enrollment guide is for illustrative purposes only. See your Benefits Summary and Master Policy for complete details about your plan.
IntroductionOnline Tools
Know Before You GoTools Help You Choose a Doctor and Understand Your Treatment » Don’t leave your family’s health and finances to chance! PEHP gives you tools and information to be an informed healthcare consumer. Go to PEHP for Members and know before you go!
Step 1 » Use the Treatment Advisor to learn more about your condition and treatment options, and learn questions to ask your doctor.
Step 2 » Use the Treatment Cost Calculator to estimate the cost of your treatment and compare cost differences among providers.
Step 3 » Determine if PEHP Value Options, including Amwell On-Demand Doctors and PEHP Value Clinics, can treat your condition or provide a starting point.
Step 4 » Use PEHP’s Find and Select a Provider to understand potential coverage pitfalls for a particular treatment or provider type, including the need for preauthorization and specific services that may be excluded.
Step 5 » Use PEHP’s Find and Select a Provider to find a doctor in your network, read about other PEHP members’ experiences with him or her, and see notes about any relevant practice patterns or other situations of which you should be aware.
Step 6 » If you still need help figuring out what to do next, call PEHP at 801-366-7555 or 800-765-7347.
Find these innovative tools at PEHP for Members at www.pehp.org. Look for them under these menus.
BENEFITSmy MONEY
my HEALTHmy
Find and Select a Provider Find Treatment OptionsFacility and Treatment Costs(Treatment Cost Calculator) (Treatment Advisor)
Autism Spectrum Disorder BenefitA brief overview of PEHP’s Autism Spectrum Disorder coverage » Children ages 2-9 (stops on 10th birthday) are eligible for the benefit, which covers up to 600 hours per year of behavioral health treatment.
» Therapeutic care includes services provided by speech therapists, occupational therapists, or physical therapists.
» Please call PEHP (801-366-7555 or 800-765-7347) for information about which autism spectrum disorders and services are covered.
» Eligible Autism Spectrum Disorder services do not accrue separately, and are subject to the medical plan’s visit limits, regular cost sharing limitations – deductibles, co-payments, and coinsurance – and would apply to the out-of-pocket maximum.
» Mental health services require Preauthorization.
» No benefits for services received from out-of-network Providers. List of in-network providers is available at PEHP for Members at www.pehp.org or by calling PEHP (801-366-7555 or 800-765-7347).
» Regular medical benefits will apply (see benefits grid for applicable co-pay and coinsurance).
IntroductionAutism Benefit
Medical Networks
PEHP AdvantageThe PEHP Advantage network of providers consists of predominantly Intermountain Healthcare (IHC) providers and facilities. It includes 34 participating hospitals and more than 7,500 participating providers.
PARTICIPATING HOSPITALS
PEHP PreferredThe PEHP Preferred network of providers consists of providers and facilities in both the Advantage and Summit networks. It includes 46 participating hospitals and more than 12,000 participating providers.
PEHP SummitThe PEHP Summit network of providers consists of predominantly IASIS, MountainStar, and University of Utah hospitals & clinics providers and facilities. It includes 39 participating hospitals and more than 7,500 participating providers.
PARTICIPATING HOSPITALS
Find Participating ProvidersGo to www.pehp.org to look up participating providers for each plan.
Beaver County Beaver Valley Hospital Milford Valley Memorial Hospital
Box Elder County Bear River Valley Hospital
Cache County Logan Regional Hospital
Carbon County Castleview Hospital
Davis County Davis Hospital
Duchesne County Uintah Basin Medical Center
Garfield County Garfield Memorial Hospital
Grand County Moab Regional Hospital
Iron County Cedar City Hospital
Juab County Central Valley Medical Center
Kane County Kane County Hospital
Millard County Delta Community Hospital Fillmore Community Hospital
Salt Lake County Alta View Hospital Intermountain Medical Center
Salt Lake County (cont.) The Orthopedic Specialty Hospital (TOSH) LDS Hospital Primary Children’s Medical Center Riverton Hospital
San Juan County Blue Mountain Hospital San Juan Hospital
Sanpete County Gunnison Valley Hospital Sanpete Valley Hospital
Sevier County Sevier Valley Hospital
Summit County Park City Medical Center
Tooele County Mountain West Medical Center
Uintah County Ashley Valley Medical Center
Utah County American Fork Hospital Orem Community Hospital Utah Valley Hospital
Wasatch County Heber Valley Medical Center
Washington County Dixie Regional Medical Center
Weber County McKay-Dee Hospital
Beaver County Beaver Valley Hospital Milford Valley Memorial Hospital
Box Elder County Bear River Valley Hospital Brigham City Community Hospital
Cache County Cache Valley Specialty
Carbon County Castleview Hospital
Davis County Lakeview Hospital Davis Hospital
Duchesne County Uintah Basin Medical Center
Garfield County Garfield Memorial Hospital
Grand County Moab Regional Hospital
Iron County Cedar City Hospital
Juab County Central Valley Medical Center
Kane County Kane County Hospital
Millard County Delta Community Hospital Fillmore Community Hospital
Salt Lake County Huntsman Cancer Hospital Jordan Valley Hospital Jordan Valley Hospital - West
Salt Lake County (cont.) Lone Peak Hospital Primary Children’s Medical Center Primary Children’s Hospital - Riverton St. Marks Hospital Salt Lake Regional Medical Center University of Utah Hospital University Orthopaedic Center
San Juan County Blue Mountain Hospital San Juan Hospital
Sanpete County Gunnison Valley Hospital Sanpete Valley Hospital
Sevier County Sevier Valley Hospital
Summit County Park City Medical Center
Tooele County Mountain West Medical Center
Uintah County Ashley Valley Medical Center
Utah County Mountain View Hospital Timpanogos Regional Hospital Mountain Point Medical Center
Wasatch County Heber Valley Medical Center
Washington County Dixie Regional Medical Center
Weber County Ogden Regional Medical Center
PEHP Medical Networks
IntroductionMedical Networks
Medical Networks
Introduction
In-Network Provider Out-of-Network Provider*
*You pay 20% of the In-Network Rate after Out-of-Pocket Maximum is met for Out-of-Network Providers. They may charge more than the In-Network Rate unless they have an agreement with you not to. Any amount above the In-Network Rate may be billed to you and will not count toward your deductible or out-of-pocket maximum.
**Some services on your plan are payable at a reduced benefit of 50% of In-Network Rate or 30% of In-Network Rate. These services do not apply to any out-of-pocket maximum. Deductible may apply. Refer to the Master Policy for specific criteria for the benefits listed above, as well as information on limitations and exclusions.
Summit, Advantage & Preferred
Traditional (Non-HSA)
Refer to the Master Policy for specific criteria for the benefits listed below, as well as information on limitations and exclusions .
YOU PAY
DEDUCTIBLES, PLAN MAXIMUMS, AND LIMITS
Plan Year Deductible Not included in the Out-of-Pocket Maximum
$350 per individual, $700 per family
Plan year Out-of-Pocket Maximum** $3,000 per individual, $6,000 per double, $9,000 per family
INPATIENT FACILITY SERVICES
Medical and Surgical | All out-of-network facilities and some in-network facilities require preauthorization. See the Master Policy for details
20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Skilled Nursing Facility | Non-custodial Up to 60 days per plan year. Requires preauthorization
20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Hospice | Up to 6 months in a 3-year period. Requires preauthorization
20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Rehabilitation | Up to 45 days per plan year. Requires preauthorization
20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Mental Health and Substance AbuseRequires preauthorization
20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
OUTPATIENT FACILITY SERVICES
Outpatient Facility and Ambulatory Surgery 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Ambulance (ground or air) Medical emergencies only, as determined by PEHP
20% of In-Network Rate after deductible 20% of In-Network Rate after deductible
Emergency Room Medical emergencies only, as determined by PEHP.If admitted, inpatient facility benefit will be applied
20% of In-Network Rate,minimum $150 co-pay per visit
20% of In-Network Rate, minimum $150 co-pay per visit, plus any balance billing above In-Network Rate
Urgent Care Facility $45 co-pay per visit
Preferred only: University of Utah Medical Group Urgent Care Facility: $50 co-pay per visit
40% of In-Network Rate after deductible
Preferred only: Not applicable
Diagnostic Tests, X-rays, Minor 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Chemotherapy, Radiation, and Dialysis 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible.Dialysis requires preauthorization
Physical and Occupational Therapy Outpatient – up to 20 combined visits per plan year. No Preauthorization required
Applicable office co-pay per visit 40% of In-Network Rate after deductible
IntroductionMedical Benefits: Traditional
Introduction
In-Network Provider Out-of-Network Provider*PROFESSIONAL SERVICES
Inpatient Physician Visits Applicable office co-pay per visit 40% of In-Network Rate after deductible
Surgery and Anesthesia 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
PEHP e-Care Amwell
Medical: $10 co-pay per visit.Mental Health: Standard benefits apply. See PEHP Value Options benefits page for details
Not applicable
PEHP Value Clinics Medical: $10 co-pay per visit Not applicable
Primary Care Office Visits and Office Surgeries $25 co-pay per visit
Preferred only: University of Utah Medical Group Primary Care Office visits: $50 co-pay per visit
40% of In-Network Rate after deductible
Preferred only: Not applicable
Specialist Office Visits and Office Surgeries, $35 co-pay per visit
Preferred only: University of Utah Medical Group Specialist Office visit: $50 co-pay per visit
40% of In-Network Rate after deductible
Preferred only: Not applicable
Emergency Room Specialist $35 co-pay per visit $35 co-pay per visit, plus any balance billing above In-Network Rate
Diagnostic Tests, X-rays 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Mental Health and Substance Abuse No preauthorization required for outpatient services. Inpatient services require preauthorization
Outpatient: $35 co-pay per visit Inpatient: Applicable office co-pay per visit
Outpatient: 40% of In-Network Rate after deductibleInpatient: 40% of In-Network Rate after deductible
PRESCRIPTION DRUGS
30-day Pharmacy Retail only
Tier 1: $10 co-pay Tier 2: 25% of discounted cost.$25 minimum, no maximum co-payTier 3: 50% of discounted cost.$50 minimum, no maximum co-pay
Plan pays up to the discounted cost,minus the preferred co-pay, if applicable.Member pays any balance
90-day Pharmacy Maintenance only
Tier 1: $20 co-pay Tier 2: 25% of discounted cost.$50 minimum, no maximum co-payTier 3: 50% of discounted cost.$100 minimum, no maximum co-pay
Plan pays up to the discounted cost,minus the preferred co-pay, if applicable.Member pays any balance
Specialty Medications, retail pharmacy Up to 30-day supply
Tier A: 20%. No maximum co-payTier B: 30%. No maximum co-pay
Plan pays up to the discounted cost,minus the preferred co-pay, if applicable.Member pays any balance
Specialty Medications, office/outpatient Up to 30-day supply
Tier A: 20% of In-Network Rate after deductible. No maximum co-payTier B: 30% of In-Network Rate after deductible. No maximum co-pay
Tier A: 40% of In-Network Rate after deductible. Tier B: 50% of In-Network Rate after deductible.
Specialty Medications, through specialty vendor Accredo | Up to 30-day supply
Tier A: 20%. $150 maximum co-payTier B: 30%. $225 maximum co-payTier C: 20%. No maximum co-pay
Not covered
IntroductionMedical Benefits: Traditional
IntroductionMedical Benefits: Traditional
In-Network Provider Out-of-Network Provider*
**Some services on your plan are payable at a reduced benefit of 50% of In-Network Rate or 30% of In-Network Rate. These services do not apply to any out-of-pocket maximum. Deductible may apply. Refer to the Master Policy for specific criteria for the benefits listed above, as well as information on limitations and exclusions.
MISCELLANEOUS SERVICES
Adoption | See limitations No charge after deductible, up to $4,000 per adoption
Affordable Care Act Preventive ServicesSee Master Policy for complete list
No charge 40% of In-Network Rate after deductible
Allergy Serum 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Chiropractic Care | Up to 10 visits per plan year Applicable office co-pay per visit Not covered
Dental Accident 20% of In-Network Rate after deductible 20% of In-Network Rate after deductible, plus any balance billing above In-Network Rate
Durable Medical Equipment, DME Except for oxygen and Sleep Disorder Equipment, DME over $750, rentals, that exceed 60 days, or as indicated in Appendix A of the Master Policy require preauthorization. Maximum limits apply on many items. See the Master Policy for benefit limits
20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Medical Supplies 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Home Health/Skilled NursingUp to 60 visits per plan year. Requires preauthorization
20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Infertility Services**Select services only. See the Master Policy
50% of In-Network Rate after deductible 70% of In-Network Rate after deductible
Injections | Requires preauthorization if over $750 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Temporomandibular Joint Dysfunction** Up to $1,000 lifetime maximum
50% of In-Network Rate after deductible 70% of In-Network Rate after deductible
PEHP FLEX$Time to Get Serious About Reducing Out-of-Pocket Costs » At open enrollment, you agree to set aside a portion of your pre-tax salary for the year to pay eligible expenses. PEHP offers two types of FLEX$: healthcare and dependent day care. Enroll in one or both.
Plan Year Contribution Limits» Up to $2,550 for healthcare expenses (May adjust annually for inflation)
» Up to $5,000 for dependent day care expenses (you and your spouse combined)
How You Contribute» Your contributions are withheld from your paycheck pre-tax. The total amount you contribute is evenly divided among pay periods.
» The total amount you choose to withhold for healthcare expenses is immediately available as soon as you begin FLEX$.
You Can’t Have an HSAYou can’t contribute to a health savings account (HSA) while you’re enrolled in healthcare FLEX$. However, you may have a dependent day care FLEX$ and/or a limited FSA and contribute to an HSA.
FLEX$ TimelineEligible FLEX$ expenses must be incurred between July 1, 2017 and September 15, 2018. You must submit claims by September 30, 2018.
Learn MoreContact PEHP FLEX$: 801-366-7503 or 800-753-7703; email: [email protected]. See instructions below to download the PEHP FLEX$ brochure or email [email protected] to request a copy.
IntroductionPEHP FLEX$
IntroductionPEHP Value Clinics
PEHP Value ClinicsConvenient and Affordable » Make one of these full-service clinics your family doctor and save! They provide all the services of a family doctor, but at a lower cost.
Medical
The STAR Plan » 25% discount on what you would normally pay an in-network provider
Traditional Plan » $10 office co-pay
Check with your employer to see which medical plans are available to you. You must be enrolled in an active PEHP medical plan to visit a medical clinic.
Look for new Value Clinics coming soon. Check www.pehp.org.
SALT LAKE CITYHealth Clinics of Utah168 N 1950 W, Ste. 201 | 801-715-3500
Midtown Clinic230 South 500 East, Suite 510 | 801-320-5660
RC Willey Employee Clinic2301 South 300 West | 801-464-7900
WesTech Wellness Center3605 S West Temple | 801-441-1002
NORTH SALT LAKE Orbit Employee Clinic845 Overland St. | 801-951-5888
FJM Clinic31 N Redwood Rd, Suite 2 | 801-624-1634
CLEARFIELDFutura Onsite Clinic11 H Street | 801-774-3265
LAYTON Onsite Care at Davis Hospital1580 W. Antelope Dr., Suite 110 | 801-807-7699
OGDENHealth Clinics of Utah2540 Washington Blvd., Ste. 122 | 801-626-3670
FJM Clinic1104 Country Hills Dr., Ste. 110 | 801-624-1633
PROVOHealth Clinics of Utah150 E Center St., Ste. 1100 | 801-374-7011
OREMBlendtec Health and Wellness Clinic1206 S 1680 W | 801-225-1281
LEHIOnSite Care at Mountain Point Medical3000 Triumph Blvd, Ste. 320 | 801-753-4600
Amwell On-Demand DoctorsA Faster, Easier Way to See a Doctor » See a doctor via mobile or web. It’s available 24 hours a day, every day, and you don’t need an appointment. Use Amwell for fevers, ear infections, cold, flu, allergies, migraines, pinkeye, stomach pain, and much more.
If You’re on a Traditional PlanEach on-demand doctor consultation costs only a $10 co-pay.
If You’re on The STAR PlanEach on-demand doctor consultation costs only $40 before you meet your deductible. After your deductible is met, you pay only a $10 co-pay.
To Get PEHP’s Lower Pricing1. Go to www.amwell.com or download the
app (available at iTunes and Google Play Store).
2. Choose “PEHP” as your health insurance.
3. Enter your subscriber ID. Find it on your benefits card. Or log in to PEHP for Members and go to “See What I’m Enrolled In” in the “my Benefits” menu.
4. Find the service key field and enter “PEHP” if you’re on the Traditional Plan or “PEHPSTAR” if you’re on The STAR Plan.
The STAR Plan: What Is It?The STAR Plan has two components: 1) A High Deductible Health Plan (HDHP), which is a qualified medical plan that meets IRS guidelines for deductibles and out-of-pocket maximums; and 2) a Health Savings Account (HSA), which is an interest-bearing account designed to be coupled with an HDHP.
YOUR DEDUCTIBLEYour deductible is the yearly dollar amount you must pay out of your own pocket for eligible medical and pharmacy expenses before PEHP begins paying benefits. The STAR Plan’s deductible is set higher than Advantage and Summit Care’s.
Understanding The PEHP STAR Plan
IntroductionThe STAR Plan
Your Out-of-Pocket Max: What Is It?It’s the annual dollar limit you will pay for covered medical services, including your deductible and prescription expenses. It protects you from large dollar claims, capping the amount you’re responsible to pay each plan year.
Do You Qualify?To be eligible, you must enroll in The STAR Plan. Also, the following things must apply to you:
» You’re not participating in or covered by a general-purpose flex account (FSA) or Health Reimbursement Account (HRA) or their balances will be $0 on or before June 30.
» You’re not covered by another health plan (unless it’s another HSA-qualified plan).
» You’re not covered by Medicare, Tricare or Medicaid.
» You’re not a dependent of another taxpayer.
How It WorksYOUR HSA
A Health Savings Account is a tax-advantaged, interest-bearing account.
Your money goes in tax-free, grows tax-free, and is spent on qualified health expenses tax-free.
It’s a great way to save for health expenses in both the
short and long term.
An HSA is like a flexible spending account, but better. You never have to worry about forfeiting HSA money you don’t spend.
Money in your HSA carries over from year-to-year and even from employer-to-employer.
IntroductionThe STAR Plan
Eligible HSA expenses include deductibles, copayments, and coinsurance, as well as all flex-eligible health expenses. However, while many expenses are HSA-eligible, they apply to your deductible and out-of-pocket maximum only if they’re covered by your health plan.
You’ll be automatically issued a debit card to access your HSA funds. Always present your PEHP card at the time of service to receive PEHP’s discounted rate. It also allows PEHP to track your spending to apply to your deductible and out-of-pocket maximum.
If you are enrolled in The STAR Plan, you can also choose to enroll in a Limited Purpose Flexible Spending Account. This is a tax savings account.
The pre-tax monies you choose to fund this account with can be used for eligible dental and vision expenses, and after you have met The STAR Plan deductible you can use these funds for eligible medical expenses.
Remember the funds in this account are use or lose. The maximum you can deposit is $2,600 for the plan year. Remember as an enrollee in The STAR Plan, you are also enrolled in the Health Savings Account (HSA).
You’ll automatically get this HSA debit card at no cost to you.
Eligible Expenses
Debit Card
Enroll in a Limited FSA
Health Equity will handle your HSA. Weber State University will make your HSA contributions directly to Health Equity into your account. You are responsible for the management of your HSA funds.
Banking
IntroductionThe STAR Plan
Contact InformationHealthEquityMember Services
Available 24 hours a day, 7 days a week
866-346-5800
Advantage & Summit Plan Comparison: STAR vs. Traditional
Benefit STAR Traditional
Does the deductible apply to the out-of-pocket maximum?
Yes No
Does the deductible apply to inpatient and outpatient services?
Yes Yes
Does the deductible apply to physician office copays?
Yes No
Will WSU contribute to my HSA? Yes Not Eligible
Benefit STAR Traditional
Employee semi-monthly cost for medical benefits $0
Individual: $27.21Double: $56.09Family: $74.88(Rates for Summit & Advantage plans only)
WSU semi-monthly Contribution
Semi-monthly:Single: $33.09Double: $66.18Family: $66.18
Not Eligible
Out-of-pocket Maximum
Medical & RX:Single: $2,500Double: $5,000Family: $7,500
Medical & RX:Single: $3,000Double: $6,000Family: $9,000
To learn more about HSAs, visit:
www.irs.gov www.ustreas.gov
The contribution maximum applies to the IRS calendar year (Jan-Dec). If you become ineligible for The STAR Plan during the course of the IRS calendar year and contributions have been made to your HSA, you may be subject to taxes and penalties. If you exceed the contribution maximum during the IRS calendar year and then drop the STAR Plan during Weber State’s open enrollment period you may be subject to taxes and penalties.
Contributions
Take Note» Weber State’s medical
benefits are based on a plan year: July 1, 2017 – June 30, 2018.
Introduction
Refer to the Master Policy for specific criteria for the benefits listed below, as well as information on limitations and exclusions .
DEDUCTIBLES, PLAN MAXIMUMS, AND LIMITS
Plan Year Deductible $1,500 single plan, $3,000 double or family plan
Plan Year Out-of-Pocket MaximumIncludes amounts applied to Deductibles, Co-Insurance and prescription drugs. Any one individual may not apply more than $7,150 toward the family Out-of-Pocket Maximum
$2,500 single plan, $5,000 double plan, $7,500 family plan
INPATIENT FACILITY SERVICES
Medical and Surgical | All out-of-network facilities and some in-network facilities require preauthorization. See the Master Policy for details
20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Skilled Nursing Facility | Non-custodial Up to 60 days per plan year. Requires preauthorization
20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Hospice | Up to 6 months in a 3-year period. Requires preauthorization
20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Rehabilitation | Up to 45 days per plan year. Requires preauthorization
20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Mental Health and Substance AbuseRequires preauthorization
20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
OUTPATIENT FACILITY SERVICES
Outpatient Facility and Ambulatory Surgery 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Ambulance (ground or air) Medical emergencies only, as determined by PEHP
20% of In-Network Rate after deductible 20% of In-Network Rate after deductible
Emergency Room Medical emergencies only, as determined by PEHP.If admitted, inpatient facility benefit will be applied
20% of In-Network Rate after deductible 20% of In-Network Rate after deductible, plus any balance billing above In-Network Rate
Urgent Care Facility 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Diagnostic Tests, X-rays, Minor 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Chemotherapy, Radiation, and Dialysis 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible.Dialysis requires preauthorization
Physical and Occupational Therapy Outpatient – up to 20 combined visits per plan year. No Preauthorization required
20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
In-Network Provider Out-of-Network Provider*
*You pay 20% of the In-Network Rate after Out-of-Pocket Maximum is met for Out-of-Network Providers. They may charge more than the In-Network Rate unless they have an agreement with you not to. Any amount above the In-Network Rate may be billed to you and will not count toward your deductible or out-of-pocket maximum.
YOU PAY
Summit & Advantage
STAR Plan (HSA-Qualified)
IntroductionMedical Benefits: STAR
PROFESSIONAL SERVICES
Inpatient Physician Visits 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Surgery and Anesthesia 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
PEHP e-Care Amwell
Medical: $10 co-pay per visit after deductible.Mental Health: Standard benefits apply after deductible. See PEHP Value Options benefits page for details
Not applicable
PEHP Value Clinics Medical: 20% of In-Network Rate after deductible
Not applicable
Primary Care Office Visits and Office Surgeries 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Specialist Office Visits and Office Surgeries 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Emergency Room Specialist 20% of In-Network Rate after deductible 20% of In-Network Rate after deductible,plus any balance billing above In-Network Rate
Diagnostic Tests, X-rays 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Mental Health and Substance Abuse No preauthorization required for outpatient services. Inpatient services require preauthorization
Outpatient: 20% of In-Network Rate after deductible Inpatient: 20% of In-Network Rate after deductible
Outpatient: 40% of In-Network Rate after deductibleInpatient: 40% of In-Network Rate after deductible
PRESCRIPTION DRUGS | All pharmacy benefits for The STAR Plan are subject to the deductible
30-day Pharmacy Retail only
Tier 1: $10 co-pay Tier 2: 25% of discounted cost.$25 minimum, no maximum co-payTier 3: 50% of discounted cost.$50 minimum, no maximum co-pay
Plan pays up to the discounted cost, minus the preferred co-pay. Member pays any balance
90-day Pharmacy Maintenance only
Tier 1: $20 co-pay Tier 2: 25% of discounted cost.$50 minimum, no maximum co-payTier 3: 50% of discounted cost.$100 minimum, no maximum co-pay
Plan pays up to the discounted cost, minus the preferred co-pay. Member pays any balance
Specialty Medications, retail pharmacy Up to 30-day supply
Tier A: 20%. No maximum co-pay Tier B: 30%. No maximum co-pay
Plan pays up to the discounted cost, minus the preferred co-pay. Member pays any balance
Specialty Medications, office/outpatient Up to 30-day supply
Tier A: 20% of In-Network Rate. No maximum co-payTier B: 30% of In-Network Rate. No maximum co-pay
Tier A: 40% of In-Network Rate. Tier B: 50% of In-Network Rate.
Specialty Medications, through specialty vendor Accredo Up to 30-day supply
Tier A: 20%. $150 maximum co-pay Tier B: 30%. $225 maximum co-payTier C: 20%. No maximum co-pay
Not covered
In-Network Provider Out-of-Network Provider*
IntroductionIntroductionMedical Benefits: STAR
MISCELLANEOUS SERVICES
Adoption | See limitations No charge after deductible, up to $4,000 per adoption
Affordable Care Act Preventive ServicesSee Master Policy for complete list
No charge 40% of In-Network Rate after deductible
Allergy Serum 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Chiropractic Care | Up to 10 visits per plan year 20% of In-Network Rate after deductible Not covered
Dental Accident 20% of In-Network Rate after deductible 20% of In-Network Rate after deductible,plus any balance billing above In-Network Rate
Durable Medical Equipment, DME Except for oxygen and Sleep Disorder Equipment, DME over $750, rentals, that exceed 60 days, or as indicated in Appendix A of the Master Policy require preauthorization. Maximum limits apply on many items. See the Master Policy for benefit limits
20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Medical Supplies 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Home Health/Skilled Nursing Up to 60 visits per plan year. Requires preauthorization
20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Infertility Services Select services only. See the Master Policy
50% of In-Network Rate after deductible 70% of In-Network Rate after deductible
Injections | Requires preauthorization if over $750 20% of In-Network Rate after deductible 40% of In-Network Rate after deductible
Temporomandibular Joint Dysfunction Up to $1,000 lifetime maximum
50% of In-Network Rate after deductible 70% of In-Network Rate after deductible
In-Network Provider Out-of-Network Provider*
IntroductionIntroductionMedical Benefits: STAR
IntroductionExplanation of Benefits
Don’t put off that test or immunization. Preventive benefits are covered at no cost to you when you see a contracted provider — even before you meet your deductible. This applies to both The STAR Plan and Traditional plan.
PEHP Pays for Preventive Benefits at 100%*YOU’RE COVERED
All groups | 01/26/17
Covered Preventive Services for Adults (Ages 18 and older)
» Preventive physical exam visits for adults, one time per plan year including:
› Blood pressure screening› Basic/comprehensive metabolic panel› Complete blood count› Urinalysis
» Abdominal aortic aneurysm one-time screening for men aged 65-75 who have ever smoked.
» Alcohol misuse screening and counseling.» Aspirin use for men ages 45-79 and women
ages 55-79, covered under the pharmacy benefit when prescribed by a physician.
» Cholesterol screening for adults of certain ages or at higher risk.
» Colorectal cancer screening for adults ages 50 to 75 using fecal occult blood testing, sigmoidoscopy, or colonoscopy.Conscious (moderate) Sedation, a type of anesthesia, along with Monitored Anesthesia Care (MAC), is included in standard colonoscopy and is not reimbursed separately, as it’s included in the payment to the rendering Physician. General Anesthesia or MAC done by any Provider other than the rendering Physician must be Medically Necessary and requires Preauthorization through PEHP.
» Depression screening for adults.» Type 2 diabetes screening for adults with
high blood pressure.
» Diet counseling for adults at higher risk for chronic disease including hyperlipidemia, obesity, diabetes, and cardiovascular disease. Intensive counseling can be delivered by primary care clinicians or by referral to other specialists including registered dietitians.
» HIV screening for all adults at higher risk.» Immunization vaccines for adults--doses,
recommended ages, and recommended populations vary:› Hepatitis A› Hepatitis B› Herpes zoster (shingles age 60 and above)› Human papillomavirus (HPV)
» males age 9-21 Gardasil» females age 9-26 Gardasil or Cervarix
› Influenza (flu shot)› Measles, mumps, rubella› Meningococcal (meningitis)› Pneumococcal (pneumonia)› Tetanus, diphtheria, pertussis (Td or Tdap)› Varicella (chickenpox)
Learn more about immunizations and see the latest vaccine schedules at www.cdc.gov/vaccines/.» Obesity screening and counseling for
all adults by primary care clinicians to promote sustained weight loss for obese adults.
» Sexually transmitted infection (STI) prevention counseling for adults at higher risk.
» Tobacco use screening for all adults and cessation interventions for tobacco users.
» Syphilis screening for all adults at higher risk.
Covered Preventive Services Specifically for Women, Including Pregnant Women
» Preventive gynecological exam, two per plan year.
» Anemia screening on a routine basis for pregnant women.
» Bacteriuria urinary tract or other infection screening for pregnant women.
» BRCA counseling about genetic testing for women at higher risk.
» BRCA testing for women at higher risk, requires preauthorization from PEHP.
» Breast cancer mammography screenings one time per plan year for women over 40. PEHP does not cover 3D mammography.
» Breast cancer chemoprevention counseling for women at higher risk.
» Breast cancer medications for women at higher risk. Tamoxifen or Raloxifene.
» Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women.Coverage allows for either a manual or electric breast pump within 12 months after delivery. Hospital grade breast pumps when medically necessary and preauthorized by PEHP are also included.
» Cervical cancer screening (pap smear) for women ages 21-65.
Continued on back
PROUDLY SERVING UTAH PUBLIC EMPLOYEES
Continued from front
» Chlamydia infection screening for younger women and other women at higher risk.
» Contraception: Food and Drug Administration approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs.› Covered services/devices include: One IUD
every two years (including removal), generic oral contraceptives, NuvaRing, Ortho Evra, diaphragms, cervical caps, emergency contraceptives (Ella, and generics only), injections, hormonal implants (including removal), Essure, and tubal ligation.
» Domestic and interpersonal violence screening and counseling for all women.
» Folic acid supplements for women who may become pregnant, covered under the pharmacy benefit when prescribed by a physician.
» Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes.
» Gonorrhea screening for all women at higher risk.
» Hepatitis B screening for pregnant women at their first prenatal visit.
» Human immunodeficiency virus (HIV) screening and counseling for sexually active women.
» Human papillomavirus (HPV) DNA test: high risk HPV DNA testing every three years for women with normal cytology results who are 30 or older in conjunction with cervical cancer screening (pap smear).
» Osteoporosis screening for women over age 60 depending on risk factors.
» Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk.
» Tobacco use screening and interventions for all women, and expanded counseling for pregnant tobacco users.
» Sexually transmitted infections (STI) counseling for sexually active women.
» Syphilis screening for all pregnant women or other women at increased risk.
Covered Preventive Services Specifically for Children (Younger than age 18)
» Preventive physical exam visits throughout childhood as recommended by the American Academy of Pediatrics including:
› Behavioral assessments for children of all ages;
› Blood pressure screening for children;› Developmental screening for children
under age 3 and surveillance throughout childhood;
› Oral health risk assessment for young children;
» Alcohol and drug use assessments for adolescents.
» Autism screening for children at 18 and 24 months.
» Cervical dysplasia (pap smear) screening for sexually active females.
» Congenital hypothyroidism screening for newborns.
» Depression screening for adolescents.» Dyslipidemia screening for children at higher
risk of lipid disorders.» Fluoride chemoprevention supplements for
children without fluoride in their water source.» Gonorrhea preventive medication for the eyes
of all newborns.» Hearing screening for all newborns, birth to 90
days old.» Height, weight, and body mass index
measurements for children.» Hematocrit or hemoglobin screening for
children.» Hemoglobinopathies or sickle cell screening
for newborns.» HIV screening for adolescents at higher risk.» Immunization vaccines for children from birth
to age 18 —doses, recommended ages, and recommended populations vary:› Diphtheria, tetanus, pertussis (Dtap);› Haemophilus influenzae type b (Hib);› Hepatitis A;› Hepatitis B;› Human papillomavirus (HPV);
» Males age 9-21 Gardasil;» Females age 9-26 Gardasil or Cervarix;
› Inactivated poliovirus;› Influenza (Flu Shot);› Measles, mumps, rubella;› Meningococcal (meningitis);› Pneumococcal (pneumonia);› Rotavirus;› Varicella (chickenpox).Learn more about immunizations and see the latest vaccine schedules at www.cdc.gov/vaccines/.
» Iron supplements for children ages 6 to 12 months at risk for anemia.
» Obesity screening and counseling.» Phenylketonuria (PKU) screening for this
genetic disorder in newborns.» Sexually transmitted infection (STI) prevention
counseling and screening for adolescents at higher risk.
» Tuberculin testing for children at higher risk of tuberculosis.
» Vision screening for all children one time between ages 3 and 5.
Coverage for Specific Drugs
Payable through the Pharmacy Plan when received at a participating pharmacy with a prescription from your doctor. Over-the-counter purchases are not covered. See applicable Benefits Summary for coverage information.» Aspirin use for men age 45-79 and women age
55-79.» Breast cancer medications for women at higher
risk. Tamoxifen or Raloxifene.» Folic acid supplements for women who may
become pregnant.» Fluoride chemoprevention supplements for
children without fluoride in their water source.» Iron supplements for children ages 6 to 12
months at risk for anemia.» Tobacco use cessation interventions, up to the
maximum approved dose and duration per plan year.
Additional Preventive Services When Enrolled in The STAR Plan(doesn’t apply to Jordan School District)(doesn’t apply to Utah Basic Plus)
Adults» Eye exam, routine. One per plan year.» Glaucoma screening.» Glucose test.» Hearing exam.» Hypothyroidism screening.» Phenylketones test.» Prostate cancer screening.» PSA (prostate specific antigen) screening.» Refraction exams.» Blood typing for pregnant women.» Rubella screening for all women of child
bearing age at their first clinical encounter.
Children» Eye exam, routine. One per plan year.» Glaucoma screening.» Hearing exam.» Hypothyroidism screening.» Refraction exams.
* PEHP processes claims based on your provider’s clinical assessment of the office visit. If a preventive item or service is billed separately, cost sharing may apply to the office visit. If the primary reason for your visit is seeking treatment for an illness or condition, cost sharing may apply. Certain screening services, such as a colonoscopy or mammogram, may identify health conditions that require further testing or treatment. If a condition is identified through a preventive screening, any subsequent testing, diagnosis, analysis, or treatment are not considered preventive services and are subject to the appropriate cost sharing.
Preventive Benefits
Understanding Your EOB (Explanation of Benefits)
We send an EOB each time we process a claim for you or someone on your plan. Go paperless and view EOBs at your myPEHP account at www.pehp.org.
We send an EOB each time we process a claim for you or someone on your plan. Go paperless and view EOBs at your myPEHP account at www.pehp.org.
AMOUNT CHARGEDThe medical provider’s (e.g., doctor, hosptial, or clinic) bill for your service.
AMOUNT INELIGIBLEThe part of the bill that includes services not covered by your plan. This is between you and the provider.
AMOUNT ELIGIBLEThis is PEHP’s maximum allowable fee (MAF). This is the most we allow contracted providers to charge for this service. However, non-contracted providers may charge more than the MAF. Avoid paying more by using only contracted providers (find them at www.pehp.org).
DEDUCTIBLEThe set amount you pay for eligible charges in a plan year before cost sharing takes place.
COINSURANCEThe percentage of the cost you must pay under your plan. You may already have paid this amount when you received services. If so, the provider’s bill may be lower than what’s shown on the EOB.
COPAYThe fixed dollar amount you must pay under your plan. You may already have paid this amount when you received services. If so, the provider’s bill may be lower than what’s shown on the EOB.
AMOUNT PAIDThe part of the bill PEHP paid.
CLAIM NUMBERKeep this number as reference if you call PEHP about your claim.
YOUR TOTAL RESPONSIBILITYThe amount of the bill the provider expects you to pay. This is between you and the provider.
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See your applicable benefits summary and master policy for complete terms of your plan.
AMOUNT CHARGEDThe medical provider’s (e.g., doctor, hospital, or clinic) bill for your service.
AMOUNT INELIGIBLEThe part of the bill that includes services not covered by your plan. This is between you and the provider.
AMOUNT ELIGIBLEThis is PEHP’s In-Network Rate. This is the most we allow in-network providers to charge for this service. However, out-of-network providers may charge more than the In-Network Rate. Avoid paying more by using only providers in your network (go to www.pehp.org).
DEDUCTIBLEThe set amount you pay for eligible charges in a plan year before cost sharing takes place.
CO-INSURANCEThe percentage of the cost you must pay under your plan. You may already have paid this amount when you received services. If so, the provider’s bill may be lower than what’s shown on the EOB.
CO-PAYThe fixed dollar amount you must pay under your plan. You may already have paid this amount when you received services. If so, the provider’s bill may be lower than what’s shown on the EOB.
AMOUNT PAIDThe part of the bill PEHP paid.
CLAIM NUMBERKeep this number as reference if you call PEHP about your claim.
YOUR TOTAL RESPONSIBILITYThe amount of the bill the provider expects you to pay. This is between you and the provider.
CPT CODEThis code for the service you received can be helpful when discussing your EOB with your doctor or PEHP.
We send an EOB each time we process a claim for you or someone on your plan. Go paperless and view EOBs at your myPEHP account at www.pehp.org.
AMOUNT CHARGEDThe medical provider’s (e.g., doctor, hosptial, or clinic) bill for your service.
AMOUNT INELIGIBLEThe part of the bill that includes services not covered by your plan. This is between you and the provider.
AMOUNT ELIGIBLEThis is PEHP’s maximum allowable fee (MAF). This is the most we allow contracted providers to charge for this service. However, non-contracted providers may charge more than the MAF. Avoid paying more by using only contracted providers (find them at www.pehp.org).
DEDUCTIBLEThe set amount you pay for eligible charges in a plan year before cost sharing takes place.
COINSURANCEThe percentage of the cost you must pay under your plan. You may already have paid this amount when you received services. If so, the provider’s bill may be lower than what’s shown on the EOB.
COPAYThe fixed dollar amount you must pay under your plan. You may already have paid this amount when you received services. If so, the provider’s bill may be lower than what’s shown on the EOB.
AMOUNT PAIDThe part of the bill PEHP paid.
CLAIM NUMBERKeep this number as reference if you call PEHP about your claim.
YOUR TOTAL RESPONSIBILITYThe amount of the bill the provider expects you to pay. This is between you and the provider.
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(Explanation of Benefits)
See your applicable benefits summary and master policy for complete terms of your plan.
We send an EOB each time we process a claim for you or someone on your plan. Go paperless and view EOBs at your myPEHP account at www.pehp.org.
AMOUNT CHARGEDThe medical provider’s (e.g., doctor, hosptial, or clinic) bill for your service.
AMOUNT INELIGIBLEThe part of the bill that includes services not covered by your plan. This is between you and the provider.
AMOUNT ELIGIBLEThis is PEHP’s maximum allowable fee (MAF). This is the most we allow contracted providers to charge for this service. However, non-contracted providers may charge more than the MAF. Avoid paying more by using only contracted providers (find them at www.pehp.org).
DEDUCTIBLEThe set amount you pay for eligible charges in a plan year before cost sharing takes place.
COINSURANCEThe percentage of the cost you must pay under your plan. You may already have paid this amount when you received services. If so, the provider’s bill may be lower than what’s shown on the EOB.
COPAYThe fixed dollar amount you must pay under your plan. You may already have paid this amount when you received services. If so, the provider’s bill may be lower than what’s shown on the EOB.
AMOUNT PAIDThe part of the bill PEHP paid.
CLAIM NUMBERKeep this number as reference if you call PEHP about your claim.
YOUR TOTAL RESPONSIBILITYThe amount of the bill the provider expects you to pay. This is between you and the provider.
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(Explanation of Benefits)
See your applicable benefits summary and master policy for complete terms of your plan.
We send an EOB each time we process a claim for you or someone on your plan. Go paperless and view EOBs at your myPEHP account at www.pehp.org.
AMOUNT CHARGEDThe medical provider’s (e.g., doctor, hosptial, or clinic) bill for your service.
AMOUNT INELIGIBLEThe part of the bill that includes services not covered by your plan. This is between you and the provider.
AMOUNT ELIGIBLEThis is PEHP’s maximum allowable fee (MAF). This is the most we allow contracted providers to charge for this service. However, non-contracted providers may charge more than the MAF. Avoid paying more by using only contracted providers (find them at www.pehp.org).
DEDUCTIBLEThe set amount you pay for eligible charges in a plan year before cost sharing takes place.
COINSURANCEThe percentage of the cost you must pay under your plan. You may already have paid this amount when you received services. If so, the provider’s bill may be lower than what’s shown on the EOB.
COPAYThe fixed dollar amount you must pay under your plan. You may already have paid this amount when you received services. If so, the provider’s bill may be lower than what’s shown on the EOB.
AMOUNT PAIDThe part of the bill PEHP paid.
CLAIM NUMBERKeep this number as reference if you call PEHP about your claim.
YOUR TOTAL RESPONSIBILITYThe amount of the bill the provider expects you to pay. This is between you and the provider.
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(Explanation of Benefits)
See your applicable benefits summary and master policy for complete terms of your plan.
We send an EOB each time we process a claim for you or someone on your plan. Go paperless and view EOBs at your myPEHP account at www.pehp.org.
AMOUNT CHARGEDThe medical provider’s (e.g., doctor, hosptial, or clinic) bill for your service.
AMOUNT INELIGIBLEThe part of the bill that includes services not covered by your plan. This is between you and the provider.
AMOUNT ELIGIBLEThis is PEHP’s maximum allowable fee (MAF). This is the most we allow contracted providers to charge for this service. However, non-contracted providers may charge more than the MAF. Avoid paying more by using only contracted providers (find them at www.pehp.org).
DEDUCTIBLEThe set amount you pay for eligible charges in a plan year before cost sharing takes place.
COINSURANCEThe percentage of the cost you must pay under your plan. You may already have paid this amount when you received services. If so, the provider’s bill may be lower than what’s shown on the EOB.
COPAYThe fixed dollar amount you must pay under your plan. You may already have paid this amount when you received services. If so, the provider’s bill may be lower than what’s shown on the EOB.
AMOUNT PAIDThe part of the bill PEHP paid.
CLAIM NUMBERKeep this number as reference if you call PEHP about your claim.
YOUR TOTAL RESPONSIBILITYThe amount of the bill the provider expects you to pay. This is between you and the provider.
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(Explanation of Benefits)
See your applicable benefits summary and master policy for complete terms of your plan.
We send an EOB each time we process a claim for you or someone on your plan. Go paperless and view EOBs at your myPEHP account at www.pehp.org.
AMOUNT CHARGEDThe medical provider’s (e.g., doctor, hosptial, or clinic) bill for your service.
AMOUNT INELIGIBLEThe part of the bill that includes services not covered by your plan. This is between you and the provider.
AMOUNT ELIGIBLEThis is PEHP’s maximum allowable fee (MAF). This is the most we allow contracted providers to charge for this service. However, non-contracted providers may charge more than the MAF. Avoid paying more by using only contracted providers (find them at www.pehp.org).
DEDUCTIBLEThe set amount you pay for eligible charges in a plan year before cost sharing takes place.
COINSURANCEThe percentage of the cost you must pay under your plan. You may already have paid this amount when you received services. If so, the provider’s bill may be lower than what’s shown on the EOB.
COPAYThe fixed dollar amount you must pay under your plan. You may already have paid this amount when you received services. If so, the provider’s bill may be lower than what’s shown on the EOB.
AMOUNT PAIDThe part of the bill PEHP paid.
CLAIM NUMBERKeep this number as reference if you call PEHP about your claim.
YOUR TOTAL RESPONSIBILITYThe amount of the bill the provider expects you to pay. This is between you and the provider.
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(Explanation of Benefits)
See your applicable benefits summary and master policy for complete terms of your plan.
We send an EOB each time we process a claim for you or someone on your plan. Go paperless and view EOBs at your myPEHP account at www.pehp.org.
AMOUNT CHARGEDThe medical provider’s (e.g., doctor, hosptial, or clinic) bill for your service.
AMOUNT INELIGIBLEThe part of the bill that includes services not covered by your plan. This is between you and the provider.
AMOUNT ELIGIBLEThis is PEHP’s maximum allowable fee (MAF). This is the most we allow contracted providers to charge for this service. However, non-contracted providers may charge more than the MAF. Avoid paying more by using only contracted providers (find them at www.pehp.org).
DEDUCTIBLEThe set amount you pay for eligible charges in a plan year before cost sharing takes place.
COINSURANCEThe percentage of the cost you must pay under your plan. You may already have paid this amount when you received services. If so, the provider’s bill may be lower than what’s shown on the EOB.
COPAYThe fixed dollar amount you must pay under your plan. You may already have paid this amount when you received services. If so, the provider’s bill may be lower than what’s shown on the EOB.
AMOUNT PAIDThe part of the bill PEHP paid.
CLAIM NUMBERKeep this number as reference if you call PEHP about your claim.
YOUR TOTAL RESPONSIBILITYThe amount of the bill the provider expects you to pay. This is between you and the provider.
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(Explanation of Benefits)
See your applicable benefits summary and master policy for complete terms of your plan.
We send an EOB each time we process a claim for you or someone on your plan. Go paperless and view EOBs at your myPEHP account at www.pehp.org.
AMOUNT CHARGEDThe medical provider’s (e.g., doctor, hosptial, or clinic) bill for your service.
AMOUNT INELIGIBLEThe part of the bill that includes services not covered by your plan. This is between you and the provider.
AMOUNT ELIGIBLEThis is PEHP’s maximum allowable fee (MAF). This is the most we allow contracted providers to charge for this service. However, non-contracted providers may charge more than the MAF. Avoid paying more by using only contracted providers (find them at www.pehp.org).
DEDUCTIBLEThe set amount you pay for eligible charges in a plan year before cost sharing takes place.
COINSURANCEThe percentage of the cost you must pay under your plan. You may already have paid this amount when you received services. If so, the provider’s bill may be lower than what’s shown on the EOB.
COPAYThe fixed dollar amount you must pay under your plan. You may already have paid this amount when you received services. If so, the provider’s bill may be lower than what’s shown on the EOB.
AMOUNT PAIDThe part of the bill PEHP paid.
CLAIM NUMBERKeep this number as reference if you call PEHP about your claim.
YOUR TOTAL RESPONSIBILITYThe amount of the bill the provider expects you to pay. This is between you and the provider.
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(Explanation of Benefits)
See your applicable benefits summary and master policy for complete terms of your plan.
We send an EOB each time we process a claim for you or someone on your plan. Go paperless and view EOBs at your myPEHP account at www.pehp.org.
AMOUNT CHARGEDThe medical provider’s (e.g., doctor, hosptial, or clinic) bill for your service.
AMOUNT INELIGIBLEThe part of the bill that includes services not covered by your plan. This is between you and the provider.
AMOUNT ELIGIBLEThis is PEHP’s maximum allowable fee (MAF). This is the most we allow contracted providers to charge for this service. However, non-contracted providers may charge more than the MAF. Avoid paying more by using only contracted providers (find them at www.pehp.org).
DEDUCTIBLEThe set amount you pay for eligible charges in a plan year before cost sharing takes place.
COINSURANCEThe percentage of the cost you must pay under your plan. You may already have paid this amount when you received services. If so, the provider’s bill may be lower than what’s shown on the EOB.
COPAYThe fixed dollar amount you must pay under your plan. You may already have paid this amount when you received services. If so, the provider’s bill may be lower than what’s shown on the EOB.
AMOUNT PAIDThe part of the bill PEHP paid.
CLAIM NUMBERKeep this number as reference if you call PEHP about your claim.
YOUR TOTAL RESPONSIBILITYThe amount of the bill the provider expects you to pay. This is between you and the provider.
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(Explanation of Benefits)
See your applicable benefits summary and master policy for complete terms of your plan.
We send an EOB each time we process a claim for you or someone on your plan. Go paperless and view EOBs at your myPEHP account at www.pehp.org.
AMOUNT CHARGEDThe medical provider’s (e.g., doctor, hosptial, or clinic) bill for your service.
AMOUNT INELIGIBLEThe part of the bill that includes services not covered by your plan. This is between you and the provider.
AMOUNT ELIGIBLEThis is PEHP’s maximum allowable fee (MAF). This is the most we allow contracted providers to charge for this service. However, non-contracted providers may charge more than the MAF. Avoid paying more by using only contracted providers (find them at www.pehp.org).
DEDUCTIBLEThe set amount you pay for eligible charges in a plan year before cost sharing takes place.
COINSURANCEThe percentage of the cost you must pay under your plan. You may already have paid this amount when you received services. If so, the provider’s bill may be lower than what’s shown on the EOB.
COPAYThe fixed dollar amount you must pay under your plan. You may already have paid this amount when you received services. If so, the provider’s bill may be lower than what’s shown on the EOB.
AMOUNT PAIDThe part of the bill PEHP paid.
CLAIM NUMBERKeep this number as reference if you call PEHP about your claim.
YOUR TOTAL RESPONSIBILITYThe amount of the bill the provider expects you to pay. This is between you and the provider.
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Understanding Your EOB
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(Explanation of Benefits)
See your applicable benefits summary and master policy for complete terms of your plan.
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Understanding Your EOBs
IntroductionUnderstanding Your EOBs
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